What are the various types of headaches according to the International Headache Society Classification System?
migraine, tension-type, cluster and other trigeminal autonomic cephalagias, other primary headaches and secondary headaches
What are the two types of migraine?
migraine with aura (visual disturbance) and migraine without aura
What causes the aura in a migraine?
decreased cerebral blood flow in occipital region; moves across the cerebral cortex; symptoms may be caused by neuronal dysfunction
What system regulates the pain associated with migraine without aura?
What are premonitory symptoms?
signs that clue a patient that they are going to experience a migraine/headache in the days to come
What are some premonitory symptoms?
neurologic (sensitive to the light), psychological (anxiety), constitutional (stiff neck and yawning), and autonomic (diarrhea and constipation)
What are acute symptoms of migraine?
throbbing pain, unilateral, N/V in 30% and sensitivity to light
How long will auras typically last?
What are diagnostic criteria for headache without aura?
At least five attacks, with each lasting 4 to 72 hours; HA has at least 2 of the following characteristics: unilateral location, pulsating quality and moderate to severe intensity; and during HA at least one of the following: N/V/both, photophobia/phonophobia, or not attributed to another disorder
What are diagnostic criteria for headache with aura?
At least two attacks and no attributable to another disorder, typical aura and at least one of the following: at least 1 symptom that develops gradually over a minimum of 5 minutes or different symptoms that occur in succession or both, each symptom lasts at least 5 minutes, but not more than 60, and HA that meets criteria for migraine w/o aura begins during the aura or follows aura within 60 minutes
What are the goals of therapy for acute treatment?
treat rapidly, restore function, minimize rescue meds, optimize self-care, cost-effective and avoid adverse effects
What are goals of therapy for chronic treatment?
reduce frequency, severity and disability, etc
What are some nonpharmacological treatments for HA?
ice, dark room or quiet environment / preventative measures like avoid triggers, keep a headache diary and good sleep/eating habits
What are some common triggers of HA?
alcohol, caffeine, chocolate, tyramine-foods, high altitude, loud noises, fatigue, stress, strenuous activity and even foods high in nitrates/chinese food
What are first-line treatments for mild to moderate acute migraine?
simple analgesic, acetaminophen, aspirin, caffeine, NSAIDs, ibuprofen, naproxen
If simple analgesics fail, what is next for mild to moderate migraine?
combination analgesics like Midrin, acetaminophen, or aspirin/butalbital/caffeine
What is third line treatment for mild to moderate migraine?
What is the final option for treatment of mild to moderate migraine?
opioid combination analgesics, butorphanol nasal spray
What is first line treatment for severe migraine?
dihydroergotamine or ergotamine tartrate or triptans
What is second line treatment for severe migraine?
opioid combination analgesics, butorphanol nasal spray as well
What can be prescribed for nausea associated with a migraine attack?
Metoclopramide or ketorolac
How long should ketorolac be used for nausea in migraine?
What are some common AE for NSAIDs?
GI side effects (N/V/D and dyspepsia) so take with food / CNS effects (somnolence and dizziness) / watch for use in elderly, history of peptic ulcer disease and renal disease
What are some examples of ergotamine tartrate?
Cafergot, Ercaf and Migergot
What are some examples of dihydroergotamine?
DHE 45 and Migranal
What are ergot alkaloids and derivatives used for?
Moderate to severe migraine
What classification of drug are the triptans?
non-selective 5-HT1 agonists (also alpha adrenergic, beta adrengergic and dopaminergic)
What additional ingredient will ergotamine tartrates contain to increase analgesic effect?
What are some side effects of ergotamine/derivatives use?
N/V, weakness, fatigue, muscle pain, severe peripheral ischemia (ergotism), and rebound headache
What class of drugs should be avoided with the ergotamine/derivatives?
triptans (allow at least 24 hours to pass before taking one)
What groups are contraindicated for use of ergotamine/derivatives?
renal failure, liver failure, coronary, cerebral, peripheral vascular disease, hypertension and pregnancy
What is the only first-generation triptan?
What are the second generation triptans?
zolmitriptan, naratriptan, rizatriptan, almotriptan, frovatriptan, and eletriptan
What are triptans indicated for?
first line treatment for moderate to severe migraine attacks
What is the triptan MOA?
5-HT1B and 5-HT1D agonist that leads to vasoconstriction / also does peripheral neuronal inhibition and inhibition of transmission of trigeminocervical complex
What should be noted about sumatriptan's duration of action?
has a short duration of action
What is common with sumatriptan use?
What are some benefits of the second-generation triptans?
longer half-lives, higher bioavailability and 2-hour effectiveness
What classes of drugs should not be used with triptans?
SSRI/SNRIs (monitor for serotonin syndrome), MAOIs, TCAs, ergot derivatives
What are some common side effects of triptans?
parasthesias, fatigue, dizziness, flushing, somnolence, and 'chest symptoms'
What groups are contraindicated for use with triptans?
ischemic heart disease, uncontrolled hypertension, cerebrovascular disease, hemiplegic/basilar migraine
What should be noted about sumatriptan in its injection formulation?
you can repeat after 1 hour prn and it has a bioavailability of 97%
Which triptan has the highest bioavailability?
What should be noted about naratriptan?
you can repeat its dosing after 4 hours prn
What can happen with overuse of medications for acute migraine?
How long should therapy for acute migraine last?
When should preventative therapy be considered with regard to acute migraine?
pain does not subside with acute therapy, frequency of attacks is >2/week, patient has a CI to the acute therapy or headache attacks are predictable
What are options for preventative therapy of migraines?
propanolol, timolol, valproate, topiramate and others
What is first line for migraine prophylaxis where headache recurs in a predictable manner?
NSAID at the time of vulnerability
What is first line for migraine prophylaxis where you have healthy or comorbid hypertension, angina or anxiety?
beta adrenergic antagonist or verapamil
What is first line for migraine prophylaxis where you have comorbid depression or isomnia?
What is first line for migraine prophylaxis where you have comorbid seizure disorder or manic-depressive illness?
Anticonvulsant followed by beta adrenergic antagonist or verapamil
What is an option for treatment of migraine that doesn't respond to other agents?
What is the efficacy of the beta blockers in reducing migraine?
What patients should use caution with beta blockers?
congestive heart failure, peripheral vascular disease, asthma, diabetes, AV conduction disturbances and depression
What are some side effects of beta blockers?
hypotension, tired/dizziness and asthma exacerbation
What antidepressants can help with migraine?
TCAs (nortriptyline or protriptyline) / SSRI or SNRI (fluoxetine) and MAOIs (phenelzine)
What is the MOA for the anticonvulsants in helping with migraine?
enhance GABA-mediated inhibition, modulate excitatory NT glutamate, inhibition of Na and Ca ion channels
What are some anticonvulsants that help with migraine?
Valproate or divalproex, topiramate, and gabapentin
What are the first side effects to occur with anticonvulsant use?
What calcium channel blocker is the most widely used for migraine?
What is a major side effect of calcium channel blockers like verapamil?
constipation and AV block
What is the appropriate trial for preventative therapy of migraine?
2-3 months (initiated low and go slow)
What should be the basis for choosing a regimen for migraine?
comorbidities and side effects
How long should continuation of medication be after frequency of attacks have diminished?
What is the most common primary headache disorder?
How long should tension headache last for it to be considered chronic?
180 days of the year
What does tension headache follow?
follows activation of supraspinal pain perception - no aura, but good for mild to moderate pain - typically triggered by stress
What are the most severe primary headache disorders?
When do cluster headaches tend to occur?
in the evening
How is pain described in a cluster headache?
unilateral, excruciating, penetrating, series lasting weeks to months and remission can be for years
What is the pathophysiology of cluster headaches?
hypothalamic dysfunction resulting in alterations in circadian rhythms and activated ipsilateral hypothalamic gray area
What are some acute treatment options for cluster headaches?
oxygen, ergotamine derivatives (take 3-7 days to break the cycle), triptans (SC sumatriptan most effective)
What are some preventative treatments for cluster headaches?
Verapamil (benefits after 1 week), lithium (with or without verapamil) and Ergotamine (with or without verapamil and lithium)